Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today's episode, this is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight podcast. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Welcome to this week's episode of the Conquer Your Weight podcast. I'm excited to bring in our guest Katie George. She is a nurse practitioner at the University of Virginia Obesity Medicine Clinic and that is local to me here in Charlottesville, Virginia. We've connected over this last year at a local medical society event and it's been really fun to get to know her and talk about how we support patients with their weight loss goals. And I think one of the things that's really important is there are a lot of other medications beyond just the GLP. So everybody has been talking about GLPs and they are great. But today, Katie George and I are going to talk also about some of the other medications that can be supportive in someone's weight loss journey. So Katie, thank you so much for joining me today. I'm really excited to have this conversation. Katie George: Thank you Dr. Stombaugh. I'm pleased to be here. Thanks for having me. So a little bit about me. I started my nursing career in the emergency room at UVA, did that for several years, then worked in the surgical trauma burn ICU for many years and then went back to nurse practitioner school and got my doctorate after that. I worked in general surgery for seven-ish years and in that I would see a lot of patients that had hernias that needed to be repaired, but we couldn't repair it because of their weight. And the weight increases, risk of hernia, recurrence increases risk of infection, and it was really, really frustrating. I saw a number of patients that felt very dismayed, just basically all they were hearing was, I'm just not doing this because of your weight. And they didn't fully understand why and there wasn't really a good resource for them to turn. It's not like they had never tried losing weight in the past. So this is when I really started to get interested about what can we do to help people on their weight loss journey. And then about almost two years ago now, I was presented with the opportunity for obesity medicine. I was like, that sounds really cool. That sounds something I can really get behind, really improving people's health, their wellbeing. And so it was a new chapter for me and I have absolutely loved every minute of it. It's really exciting to learn the pathophysiology of the disease process. It's super complex and I'm a geek and I love pathophysiology and all that sort of stuff. So that's been really cool. And then to learn how to support patients and the options we have available to support them. So today we're going to talk about I believe some of the non GLP-1 options because the GLP-1s are always in the news, but there are a lot of other medications we do use and that can be very effective to help with weight loss when we can't get access to a GLP-1. Dr. Sarah Stombaugh: Yes, absolutely. And sometimes I think the conversation over the last two years, this GLP, GLP, GLP, I'm really pleased that people are interested. They're excited. It's opened the door and the conversation and started to decrease some of that stigma that we may have about using medications to support the weight loss journey. And there's so much else that's out there. So especially for someone like yourself who works in a program, you guys take insurance. There's patients who have Medicare patients who have Medicaid, and those programs do not always cover some of the GLP or even some programs may cover them, but it may be part of step therapy where you have to do other medications before a GLP may be covered. Tell us a little bit about bit your practice. When someone comes in and they're interested in losing weight, how are you starting to talk to them about the different available options? Katie George: Sure. So I think you hit on a good point. For example, I have a fair number of patients that have Medicaid and a year ago Medicaid, we'll say roughly would cover GLP-1s would goers upbound or sex enda for a BMI greater than 30. And they have significantly changed that. And pretty much the way they've written it now, it makes it impossible to get someone on a GLP-1 that has Medicaid insurance and then even if their BMI drops below 40, which would be the goal of therapy to lose weight, then they won't cover it anyways. And I understand these drugs are expensive, so these things are always changing and that's what I tell patients. I tell patients my role in this is optimizing the lifestyle aspects, which is going to be high protein, relatively low carb diet, physical activity exercise with a focus on strength training so we can increase metabolism and keep this weight off. And then medical therapy. And what I can do with medical therapy depends on your medical history and what your insurance will pay for. And so then once we're there, I look at their insurance and see is GLP-1 going to be an option if that's appropriate for the patient? And if it is, I may mention that. But my caveat to that, I explained that there's kind of two different pots. There's the GLP-1s that are very effective. They get a lot of attention in the media, they work very well. The downfalls to them in my mind are the access. And I don't see that consistently changing in the near future. I currently have a lot of patients who had an insurance that was covering and then all of a sudden they're not. Then I'll have multiple patients sometimes a day in a panic messaging me saying, oh my gosh, this isn't covered anymore. We didn't know this was coming. And that can be pretty unsettling to patients. So now if I start a GLP-1, I tell them, I say, look, I can't guarantee access to GLP-1 for any patient for the rest of their life if needed, let alone the next year. A year and a half ago we had a national shortage and even if we could have insurance approval, we couldn't start anyone on. We couldn't find them. So while they're amazing drugs and I truly believe they really improve health from multiple standpoints, there's trouble with access. So then the other part is the oral anti-obesity medications, and these are things that people really haven't heard about as much and there's a variety of different options there. And I'm happy to discuss which drugs I'd use when, but I look at the patient's medical history, there are certain things in their history that may preclude that we would use a certain drug like phentermine or it may be that if someone is already on narcotics daily for chronic pain, I can't use naltrexone for them. So there are things like that I look at, I figure out what things are absolute contraindications. I look at what is their struggle? Are they really doing a great job? They're really eating that lean healthy protein. They're exercising, they're doing strength training, they're doing all the right stuff, and this is just a very metabolic process. Then I need to increase their metabolism. So I might tailor my therapy towards that. Or I have one patient who says three weeks out of the month I do great, but around my cycle I can't control my sweet cravings. So with her, we added a little bit of metformin for some insulin resistance. She takes that daily and then around her cycle, she'll take naltrexone to reduce sweet cravings and that's worked really well for her. So it's totally tailoring it to individual patients. Dr. Sarah Stombaugh: I love that approach. And I think that's where we look at these mega telehealth conglomerates and where people are filling out a survey online, for example, before they receive medication in the mail. And the reality is sitting down face-to-face with someone, even if that is potentially in a telehealth capacity, but that you're having an entire visit that's dedicated to understanding your entire medical history and understanding the reason by which you're struggling with weight. And one of the studies that is most fascinating to me was the study that looked at sort of pre the newer GLP. So it was a study done in the early mid 20 teens, like 2015 or so, and it looked at Contrave, which is the combination of appropriate naltrexone. It looked at Qsymia, the combination of phentermine, topiramate, it did have Saxenda in there, the liraglutide, which is the older of the GLP medications of course, but for my listeners and then for people who had phentermine alone and then also included some of the older medication like Lorcaserin that has been taken off the market. But what they did is they looked at people and looked at if they had, like you said, metabolism versus cravings versus what was it? Was it hungry brain? Was it hungry gut? Was it their cravings? And when they would tailor to a patient a specific medication. The interesting thing is that when we look at the efficacy of some of these medications, the Qsymias, the Contraves, the phentermine, and you look at the data sometimes it's kind of sad. It's like someone might lose 5%, 8%, 9% of their total body weight. And people are like, well, who cares about that? But when you start to combine that then with the reason that the person is struggling with their weight in this study, they saw 15 plus percent total body weight loss over a year. I know that's something you've seen a lot in your practice. Tell me a little bit and expand on maybe some specific examples of patients for whom you've been able to tailor medication and have done phenomenally, maybe more than we would've even expect with some of the GLP medications. Katie George: Sure. So I think that's another thing I tell patients when we're talking about the oral medications, for example, if I have someone where I have all the options available, I tell people, I don't know how you individually are going to do with this until I start it. The GLP-1s are a little bit more predictable. The side effects and interactions are less of a concern with GLP-1s than they are with oral medications. So a lot of this, I tell people what one person does amazing with and they have no side effects and they have a great response and they might lose far more than the research says they would on average the next patient patient either will call me in three days and be like, I hated the way that made me feel. I'm never taking that again or I've been taking it. I don't feel like it's made any difference at all. So it's a little bit more trial and error, which can be frustrating. I think our society naturally is always like we want immediate results and certainly with weight loss, when you've been struggling for so long and you're trying and then you take this step and you hear about all these GLP-1s and you see people losing weight quickly, a lot of people come in hoping and watching that, understandably. And I have to tell people that may or may not be the case. It is more important that we go slow and figure out what you do well with and then we can optimize efficacy from there once we know what works for you. So I have one patient who's in her mid to late fifties and she didn't have GLP-1 coverage and her BMI was over 50. And in my head I'm like, gosh, this is going to be tough. But she responded beautifully to metformin and we titrated that up over time to 2000 milligrams, four tablets a day to treat her insulin resistance from that aspect, and then low-dose phentermine, 15 milligrams. She's been on it nine-ish months maybe, and she's done beautifully. I think she's lost over 20% of her body weight. She feels wonderful. It was interesting. I remember in her, I started the metformin first and then we added in the phentermine. And even with the metformin, and some people will tell you this, some people will say, gosh, I really think that helped take the edge off my hunger. I think it helped take the edge off my cravings. I remember she specifically said she felt less inflammation starting it, which kind of makes sense. So that was a beautiful combination for her. I might have someone else who I put on 15 milligrams of phentermine and metformin and they don't do well at all. So I find that with the oral drugs, it is very patient dependent and variable. And I agree the literature is really hard to make sense of. When patients ask me how much weight can I expect to lose, I can really clearly tell you how much the average weight loss reported with Zepbound or Wegovy is. With the oral stuff, it's more gray. So I tell patients we'll figure it out when we get there and we try to tailor it. So if I have someone where I want to increase their metabolism and they don't have any contraindications, then phentermine may be the drug I'm starting with, which will help decrease appetite. Sometimes I'm not trying to decrease appetite. Sometimes I'm telling people, you have to eat more. If we do this, you have to eat more protein. I'm doing this just to raise your natural metabolism. You're already doing a really great job. Other people, I am using it to help with the hunger control, and they'll say that I do need some help with that. And in that person then maybe all geared towards phentermine and Topiramate, whether that's brand name Qsymia, but frankly, a lot of insurances don't cover that. So a lot of times I'm doing phentermine by itself and then topiramate and going slowly with the topiramate. Topiramate is another drug where some people do great and have no side effects. Other people will have what we call dopamax at a fairly low dose where they kind of feel out of it or slow down and they don't tolerate it well. I think any of these drugs, when you're titrating up, you start low, you go slow and you only go up if you feel better. I have one woman I'm thinking of who's in her thirties, and over the course of two years we started with one or two medications. I think with her we started Phentermine Metformin. She did well with that, lost about 10% of her body weight. She then felt more comfortable. So then she was able to increase her exercise more, but her weight loss was starting to plateau. So we increased dose of phentermine, helped a little bit more. She plateaued again, we added in and at that time she started to say, Hey, hunger is doing okay, but my sweet cravings are really getting out of control. So then we added in Naltrexone for her. That is part of the combination in Contrave, right? Contrave brand name drug has bupropion, commonly known as Wellbutrin, as an antidepressant. And then Naltrexone. Naltrexone works in the brain to reduce in the reward center, the hypothalamus to reduce cravings. Also used for alcohol use disorder. We know that food can be very addictive, certainly the food generated in our society and it's not all that different from any other addiction and turns out a lot of the medications that help with these cravings help reduce that. So adding in naltrexone for her really helped with sweet cravings. Once she was doing fine with it, we went up to a higher dose of naltrexone and then after a while she was plateauing again, we're on maximum dose metformin, maximum dose phentermine, maximum dose naltrexone. So we talked about adding in Topiramate. She had no contraindications to that. So we added that in. And in total, let me pull up her exact numbers. She's lost over 75 pounds, more than 25% of her body weight. She has done incredible. And through that time too, this is someone who started out in our initial visit, and that's really scary, that first visit for the patient saying, I avoid taking pictures with my kids. That breaks my heart when I hear that I don't feel comfortable with my spouse. That is so important. And over time, she has gained so much confidence she's been able to be more physically active because it doesn't hurt to move. She's doing a phenomenal job and her excellent lifestyle changes are totally what's supporting making these medications even more effective. But it's a really cool example of we can get significant weight loss off now. She's probably an outlier, but we can get significant weight loss even without GLP-1s. Dr. Sarah Stombaugh: Yeah, absolutely. And I love, one of the things you're sort of alluding to is that when we look at these medications, the studies looked at contra, right? They look at the bupropion naltrexone, the studies look at qia and this phentermine, topiramate. There's not ever studies of the different combinations. And I think one of the things that we've really learned in the obesity medicine space is that different people may need different components. And can we take, I mean metformin you mentioned I use metformin all of the time. Metformin is not FDA approved for the treatment of weight loss, right? Metformin is a medication, interestingly, not even approved for pre-diabetes. It's actually just approved for type two diabetes. It's totally insane. But it's like these medications that have been around for decades. I mean, I think Metformin's been around since the eighties, and so we look at metformin, it's not going to go back through an FDA approval process to get approval for these other things. They're not going to get the funding for it. It's been a generic medication for a long time. And so these medications though, they're very effective. Can we utilize them either on their own, but then especially in combination, so can we start to create these combinations where someone is taking a metformin to support their insulin resistance and a phentermine to support their cravings. There's not any studies out there that look at a large population and study that in a randomized control trial, for example. And I think there's some people who are really want to have those trials, want to have that evidence-based medicine. I believe very strongly of course, in doing that. And can we use our logic of what does the person study or what is the person dealing with? Can we take these different components and best support a person and find that some people get really, really phenomenal results, Katie George: Right? Absolutely. And I think funding's the key, right? I remember when I got into this, I was so excited and when I realized there were no studies, I'm like, oh, this is so cool. We're going to do this. And then I'm like, oh, yeah, I don't have time to do this. We're funding. But I agree it really needs to be done. I think a lot of us that practice in obesity medicine do this commonly. A lot of the medications we use are off-label, which sounds like a bad term, but when a primary care gives someone metformin when they pre-diabetes to prevent them from getting diabetes, which is the correct medical thing to do, no one cares about that. But if I use pre-diabetes to treat insulin resistance to help someone lose weight, some people will get judgmental about that. And that just speaks to stigma, which I'm sure you've had talks on before and I won't get into. But it really is interesting, and I think I wish there was a way to pull obesity medicine specialists and patient profiles and medications that they're on and to look at those sorts of things because easy to publish case reports of these people that we have that have done really well. No one looks down upon if someone prescribes topiramate for migraines and then they prescribe Wellbutrin for depression and maybe they do have diabetes, so they're also on metformin. No one cares when you combine those three drugs for that. But if you're doing it for obesity, then people get a little skeptical about it. And it's like everything in my mind is a risk birth benefit. There is a risk to everything we do, whether that is a medication, whether that is a surgery. There is also a risk to not doing and not treating a disease. And I think at the end of the day, that's it. And then this is again where it comes down to the individualized patient and combining those things. If we get significant weight off, if I get 40 pounds of adipose inflammatory, adipose tissue off, the improvements in that person's health, the reduction in the risk of developing diabetes, heart disease, joint problems, all the things that go along with this cancer reduction risk, that is so worth it to me to the potential risks of side effects that may never happen. And as you know, there's a lot of negative attention or worry about phentermine use, and phentermine is a drug, but it's been around for a long time. I think it was 1960, it got approval, and then in the nineties it got some bad press when it was combined with a different drug called fenfluramine as en-phen known in the nineties. And some people lost a lot of weight, and we then found out that fenfluramine was dangerous, especially in people that had cardiac or valvular disease. So fenfluramine was pulled off the market, but because of that, this association, because phentermine was used with it, has always carried more restrictive rules. For example, the state of Virginia has more restrictive rules around phentermine prescribing than most other states. Then when I tell patients, look, by law I have to do this, I have to get an EKG and make sure your thyroid's okay, even though I think your thyroid's totally fine. It was checked a year ago. Clinically that doesn't make sense to recheck, but these laws are in place and that adds a level of skepticism, unfortunately for patients and makes a barrier that doesn't necessarily need to be there. We thankfully do have bigger studies now of people on phentermine and on phentermine for longer periods of time. I think it was 2019, it was a really large study around 50,000 people, retrospective study where they looked back at people on phentermine, some of them up to two years, no increased risk of any cardiovascular event. Obviously, those patients that were on phentermine longer and consistently, not like three times a week, lost more weight. And at the end of the study, they actually had a lower blood pressure that's never reported. We're always worried about increasing blood pressure. And while that's something you do have to watch, I say it's rare and you can almost tell what patients are going to have a little bit of increase in their blood pressure when you start it, and we talk about it and we have a plan for it. So I think the real benefits are really undermined unfortunately by a history. And the more recent evidence that shows the risk benefit profile is actually pretty favorable. That's not as well known, Dr. Sarah Stombaugh: And we haven't seen any change in terms of the prescribing, right? It's still a controlled substance, for example, while Virginia does have some limitations, I'm grateful we're at least allowed to prescribe it long-term, right? Certain states are like, you can do three months on and then you have to do three months off, and that is not evidence-based at all. And so I'm grateful that we're not in that situation, but these things, as you say, just increase that skepticism, increase our worry that it is a more dangerous drug. I think there's a lot of perception too from the medical community at large that because it's a controlled substance, it must be really addictive. I've had patients who it's so effective for them that if they're told they can't get the medication, they almost exhibit behaviors with, I need this, I want this. And then they get labeled as drug seeking, which can be really, really challenging because this is a medication that it doesn't make people high. It doesn't make people feel, it's not like the opioids, right? It's a medication that's really just working on the appetite. And so it's a phenomenal drug, I will say to anyone who's listening, especially when there's not coverage for medications. This is where seeing someone who's board certified in obesity medicine who's been doing this for a while, this is where that value is because we're seeing on every single corner that med spas are popping up and online telehealth programs where you can just get a GLP delivered to your door, and that's a whole other conversation for another time. But there may be other medications that are safe, effective, affordable, affordable, affordable. I mean, that's the piece of this too. A lot of these medications are, we're thinking about them for long-term use. And the narrative right now of jumpstart your weight loss journey is really concerning to me because we've been, I mean, the weight loss industry has always been sort of predatory. There's always this six week program, this 12 week program, jumpstart this, jumpstart that, and the GLP is used in that capacity. While that may be possible for a small subset of patients, for the vast majority of people in any sort of weight loss journey, how you lose weight is how you're going to keep weight off. And so what does this look like? Not six months from now, but five years from now, 10 years from now, decades from now, we want to have a really good plan, and some of these other medications may make more sense in the long term. Katie George: Absolutely. And you hit on several things. I think the idea that phentermine may be addictive, and I know you know this, but phentermine, some people will say, well, it's basically speed. I've had medical providers say this to me or it's an amphetamine. I'm like, no, it's not. It is similar, but some very smart chemists a long time ago modified it so that I think they added a carbon group or something like that. And what that does is changes where amphetamine is very addictive. It releases a lot of dopamine, which makes you really happy, and that creates a very strong reward. Circuit phentermine is changed, so it doesn't release much dopamine, and that is key. So I am very sensitive to addiction. I did general surgery and worked with a lot of narcotics for a long time, and I'm very well aware of when someone is starting to develop a substance use disorder. I honestly have not seen it. I have not seen anyone act like that with phentermine. And we talk about it, and I always say, look, if you're starting to feel that way, you talk to me about it. I really don't. I agree though. Again, I had a patient not long ago who his primary care had started him on phentermine. He had worked up, he was doing amazing. And then I don't know if there was change in providers, but then he was just taken off at cold Turkey. He lost a ton of weight, his blood pressure went down. He was doing so well then just like cold turkey without even a visit, just said like, oh, no, it's been more than three months. He had been on it nine months, and they were just like, we can't do it anymore. Never explained why I think this happens to a lot of people. Then it throws them in this tailspin. When you are on a higher dose for a while, that is something you should taper down, not because you're going to withdraw per se, but it's because your body's used to having that, and that does not feel comfortable coming off. So that's totally something that people shouldn't be doing, and that's why it's helpful to see someone that is really comfortable and knows how to use these medications so that if we decide we want to stop for some reason, then we taper down if necessary. And then we have plan B so that if weight or hunger or cravings are coming back, we have a plan so the patient isn't left panicking and feeling uncomfortable. What was I going to say about the cost? Absolutely right. Phentermine with a GoodRx price is like $6 in some pharmacies, and the GLP-1s, as we know out of pocket, are around $1,500 depending on what you're looking at. It's a vast cost difference. So while the GLP-1s create so much excitement, I think the reality of keeping someone on them longterm right now, it is not consistent and stable. Dr. Sarah Stombaugh: Absolutely. I appreciate that information. I will say, I think you and I could talk all day long. I think we could sit around the first time you and I met, actually, I think we got on a very similar conversation. I think Katie and I could just talk all day long about these type of things. This has been so fun getting the opportunity to bring you on and share with my audience. Let me ask you, before we wrap up, is there anything that you haven't said yet that you think is really important for my audience to hear Katie George: As I was thinking about this? I think it's just some general concepts that you've probably already covered that extend beyond this one. Don't go in with a plan thinking, I want this drug and if I can't have this drug, I won't be successful. I think that already limits how successful a patient will be open to things. Be in contact with your provider if something's not working before you just stop cold turkey. Unless it's a really bad side effect, talk to them. And it may be that we just need to decrease the dose or we can help mitigate side effects so we can try something else. And then also just how difficult it can be in our daily society. I actually have, this is funny, this is not what we're talking about, but I was like, this is something really, these are two bags of granola. This is how difficult it is to be healthy in our society and why it takes someone to really help work through this. So because our society has so much marketing about healthy, so they're writing protein on everything, but then they'll add sugar back in the backend. This is a type of keto granola I used to get that has mostly healthy nets and sunflower seeds and things like that. Not a lot of carbohydrates or sugar. They switched it. It's the exact same bag, exact same colors, still has coconut and cashew. Ton of sugar. Ton of sugar, wow. Exact same product. And I'm a healthcare provider, and I bought the same bag thinking it was the same thing. And I just wanted to add that in. It's a totally different piece, but our society makes it so difficult to be healthy, and you have to be so savvy in looking at that. So that's just another piece that I don't want people to feel frustrated. This is such a hard journey in our society, and it's not that people are doing anything wrong, it's there's so many different aspects to treating this disease in our society. Dr. Sarah Stombaugh: Yes, absolutely. And I appreciate you bringing that piece in because I think we have traditionally looked at weight with the stigma from society. And so it's your fault. You're not working hard enough, you're not eating. And when we look at our food environment, we look at the culture we live in, it's like, I don't know how anyone doesn't struggle with this. Right? It's such a prevalent issue in our country for a vast multitude of reasons. And so I really appreciate that because there shouldn't be any blame and shame. And if you're working with a provider who's giving you blame and shame, it's time to find a provider who's going to support you in a much more comprehensive and empathetic way. And so I appreciate you saying that. And tell us if people are interested in learning more about you, if they're interested in working with you, where can they do that? Katie George: Sure. So I work at the OBC Medicine Center at UVA Health. Currently, we're limited, as you can imagine. There are a vast number of people that want to get treated for weight, and we're working on expanding our team. So if anyone's interested, reach out to us. So at the moment, we're not accepting new referrals, but hope to be in the near future. Dr. Sarah Stombaugh: That's exciting. Well, I'm so grateful to have you in the community. Thank you so much for joining me today, and for everyone who's listening, thanks for joining this episode. If you ever have questions, you can reach out to us at info@sarahstombaughmd.com. We'll have all of my information. And then of course, Katie's as well in the show notes. Have a nice day.